test question

Nursing Students General Students

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1.the client had an abdominal aortic aneursym repair two days ago. Which intervention shoudl the nurse implement first?

a.assess the client bowel sounds

b. administer iv prophylactic antibiotic

c.encourage the client to splint the incision

d.ambulate the client in the room with assisstance

2.Which assessment data would require immediate intervention by the nurse for the client who is 6 hrs post-op abdominal aortic aneurysm repair?

a. absent bilateral pedial pulses

b.complaints of pain at the site of the incision

c.distended tender abdomin

d.an elevated temperature of 100*F.

I was going with d on the first one and a in the second one. Any suggestions would be greatly appreciated. Thanks :uhoh3:

Specializes in Med-Surg, Geriatrics, Ambulatory Care.

I say A for both

my rationale is...

post-operatively, could have paralytic ileus (the other answers are less on the hierarchy)

and Airway, Circulation, Breating (#2 - absent bilateral pulses!! - impaired circulation!!!)

Specializes in Cardiac.

I agree that 6 hours after surgery, most of my pts abdomens are still distended and tender.

I go with A. Absent pedal pulses are a bad, bad thing.

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